American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. American Academy of Child and Adolescent Psychiatry

Positive psychological functioning, resilience and styles of coping as buffers against suicidal behaviours. A case-control study

BACKGROUND

Studies in the literature mainly focus on understanding the risk factors for suicide, giving little relevance to protective variables. This study aimed at exploring the specific contribution of protective variables (resilience, coping and psychological well-being) in hospitalized suicide attempt (SA) makers.

METHODS

We recruited 50 inpatients who made a SA before admission and 50 inpatients with no history of SA matched for DSM-5 diagnosis, gender and age. Protective variables were evaluated with: Brief COPE questionnaire, Dispositional Resilience Scale (DRS-15), Psychological Well-Being Scale (PWB-18). Psychopathological features and symptom severity were assessed with: Global Assessment of Functioning Scale (GAF), Rapid Dimensional Assessment Scale (SVARAD), Brief Psychiatric Rating Scale (BPRS), Clinical Global Impressions (CGI), Hamilton Depression Rating Scale (HDRS17).

RESULTS

The DRS-15 total score was significantly lower in SA makers. SA makers displayed significantly lower scores on the Engagement and Cognitive Restructuring subscales of the Brief COPE. On the PWB-18, the Self-Acceptance subscale score was lower in SA makers.

LIMITATIONS

The small sample size suggests the need for caution in interpreting the results. Matching was carried out by excluding diagnoses of personality disorders.

CONCLUSIONS

Patients hospitalized following a SA are more often diagnosed with personality disorders, have deficit areas concerning resilience and coping, and lower psychological well-being compared to patients without a SA. When approaching a patient who has committed a SA, it may be useful to evaluate protective variables as well as risk factors, and encourage the development of adaptive coping mechanisms and positive self-evaluation through more dynamic therapeutic paths.

Remission, Recovery, Relapse, and Recurrence Rates for Suicide Attempts and Nonsuicidal Self-Injury for Suicidal Youth Treated With Dialectical Behavior Therapy or Supportive Therapy

OBJECTIVE

To evaluate rates of remission, recovery, relapse, and recurrence in suicidal youth who participated in a clinical trial comparing Dialectical Behavior Therapy (DBT) and Individual and Group Supportive Therapy (IGST).

METHOD

Participants were 173 youth, aged 12 to 18 years, with repetitive self-harm (including at least 1 prior suicide attempt [SA]) and elevated suicidal ideation (SI). Participants received 6 months of DBT or IGST and were followed for 6 months post-treatment. The sample was 95% female, 56.4% White, and 27.49% Latina. Remission was defined as absence of SA or nonsuicidal self-injury (NSSI) across one 3-month interval; recovery was defined across 2 or more consecutive intervals. Relapse and recurrence were defined as SA or NSSI following remission or recovery. Cross-tabulation with χ2 was used for between-group contrasts.

RESULTS

Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA in DBT than for IGST. Across treatments and time points, SA had higher remission and recovery rates and lower relapse and recurrence rates than NSSI. There were no significant differences in NSSI remission between conditions; however, participants receiving DBT had significantly higher NSSI recovery rates than those receiving IGST for the 3- to 9-month, 3- to 12-month, and 6- to 12-month intervals.

CONCLUSION

Results showed higher percentages of SA remission and recovery for DBT as compared to IGST. NSSI was less likely to remit than SA.

PLAIN LANGUAGE SUMMARY

This study examined rates of remission, recovery, relapse, and recurrence of suicide attempts (SA) and nonsuicidal self-injury (NSSI) among the participants in the CARES Study, a randomized clinical trial of 6 months of Dialectical Behavior Therapy or Individual and Group Supportive Therapy. 173 youth aged 12 to 18 years participated in the study and were followed for 6 months post treatment. Over 70% of the sample reported remission of SA at each treatment and follow-up interval. There were significantly higher rates of remission and recovery and lower rates of relapse and recurrence for SA among participants who received Dialectical Behavioral Therapy. Across both treatments, remission and recovery rates were lower and relapse and recurrence rates were higher for NSSI than for SA. These results underscore the value of Dialectical Behavioral Therapy as a first line treatment for youth at high risk for suicide.

DIVERSITY & INCLUSION STATEMENT

We worked to ensure race, ethnic, and/or other types of diversity in the recruitment of human participants.

CLINICAL TRIAL REGISTRATION INFORMATION

Collaborative Adolescent Research on Emotions and Suicide (CARES); https://www.

CLINICALTRIALS

gov/; NCT01528020.

Life stress and suicidality mediated by insomnia and depressive symptoms in adolescents: a three-wave longitudinal study

STUDY OBJECTIVES

Little empirical work has investigated the associations between life stress (LS), insomnia, depression, and suicidality in multi-wave longitudinal studies. With three waves of data collection 1-year apart, this longitudinal study with a large sample of adolescents examined the predicting effects of LS on suicidality 1-year later and 2 years later and the mediating roles of insomnia and depression in the LS-suicidality link.

METHODS

A total of 6995 adolescents (mean age = 14.86 years, 51.4% male) participated in a three-wave longitudinal study of behavior and health in Shandong, China. A self-administered structured questionnaire and standardized scales were used to assess suicidality (including suicidal thought [ST], suicide plan [SP], and suicide attempt [SA]), LS, insomnia, and depression in 2015 (T1), 1-year later (T2), and 2 years later (T3). Mediation effects were examined with path models.

RESULTS

The overall prevalence rates of past-year suicidality were 13.4% at T1, 10.0% at T2, and 9.5% at T3, respectively. The prevalence rates of suicidality across T1-T3 significantly increased with elevated levels of baseline LS, insomnia, and depression (p < .001). Path models indicated that the relationship between baseline LS and suicidal ideation (i.e., ST/SP) 2 years later was significantly mediated by both insomnia and depression. Depression was also a significant mediator between LS and SA.

CONCLUSIONS

LS is a significant predictor of suicidality 1-2 years later in adolescents. Depression mediates the association between LS and suicidal ideation and suicide attempt while insomnia appears to be a mediator for suicidal ideation rather than suicide attempt.

Factors within the clinical encounter that impact upon risk assessment within child and adolescent mental health services: a rapid realist synthesis

Background

Risk assessment is a key process when a child or adolescent presents at risk for self-harm or suicide in a mental health crisis or emergency. Risk assessment by a healthcare professional should be included within a biopsychosocial assessment. However, the predictive value of risk-screening tools for self-harm and suicide in children and adolescents is consistently challenged. A review is needed to explore how best to undertake risk assessment and the appropriate role for tools/checklists within the assessment pathway.

Aims

To map research relating to risk assessment for child and adolescent mental health and to identify features that relate to a successful risk assessment.

Objectives

To review factors within the clinical encounter that impact upon risk assessments for self-harm and suicide in children and adolescents: i. to conduct a realist synthesis to understand mechanisms for risk assessment, why they occur and how they vary by context ii. to conduct a mapping review of primary studies/reviews to describe available tools of applicability to the UK.

Data sources

Databases, including MEDLINE, PsycINFO®, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library, were searched (September 2021). Searches were also conducted for reports from websites.

Review methods

A resource-constrained realist synthesis was conducted exploring factors that impact upon risk assessments for self-harm and suicide. This was accompanied by a mapping review of primary studies/reviews describing risk-assessment tools and approaches used in UK child and adolescent mental health. Following piloting, four reviewers screened retrieved records. Items were coded for the mapping and/or for inclusion in the realist synthesis. The review team examined the validity and limitations of risk-screening tools. In addition, the team identified structured approaches to risk assessment. Reporting of the realist synthesis followed RAMESES guidelines.

Results

From 4084 unique citations, 249 papers were reviewed and 41 studies (49 tools) were included in the mapping review. Eight reviews were identified following full-text screening. Fifty-seven papers were identified for the realist review. Findings highlight 14 explanations (programme theories) for a successful risk assessment for self-harm and suicide. Forty-nine individual assessment tools/approaches were identified. Few tools were developed in the UK, specifically for children and adolescents. These lacked formal independent evaluation. No risk-screening tool is suitable for risk prediction; optimal approaches incorporate a relationship of trust, involvement of the family, where appropriate, and a patient-centred holistic approach. The objective of risk assessment should be elicitation of information to direct a risk formulation and care plan.

Limitations

Many identified tools are well-established but lack scientific validity, particularly predictive validity, or clinical utility. Programme theories were generated rapidly from a survey of risk assessment.

Conclusions

No single checklist/approach meets the needs of risk assessment for self-harm and suicide. A whole-system approach is required, informed by structured clinical judgement. Useful components include a holistic assessment within a climate of trust, facilitated by family involvement.

Study registration

This study is registered as PROSPERO CRD42021276671.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135079) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.

Youth Suicide in India: A Critical Review and Implication for the National Suicide Prevention Policy

Youth suicide is a significant public health problem in Low-and middle-income countries (LMIC), including India. It is a distinct phenomenon with various bio-psycho-social determinants. Despite this, comprehensive literature on this topic is lacking from India. Thus, the current paper aimed to review the available literature on youth-suicide from India and other LMIC, discusses the contentious issues, including potential solutions for the possible roadblocks, and provides recommendations for the national suicide-prevention policy and strategy (NSPPS) in the Indian context. We found that the magnitude of youth suicide in India is substantial with the distinct bio-psycho-social determinants. Although, youth-specific suicide prevention and therapeutic intervention do exist; its feasibility and effectivity in the Indian context are yet to be established. The is an urgent need for the NSPPS; experiences from other LMIC should be incorporated while framing such policies. More research is required from India in this area.

Suicide prevention: What does the evidence show for the effectiveness of safety planning for children and young people? - A systematic scoping review

WHAT IS KNOWN ON THE SUBJECT?: Suicide prevention is an international healthcare priority. There is an urgent need to use approaches that are helpful and follow research evidence. Safety planning is now widely used in suicide prevention; however, it was developed for use with adults, and little is known about its effectiveness for children/young people. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This systematic scoping review brings together all research evidence since 2008 that reported how effective safety planning is for children/young people. Findings highlight that when healthcare professionals help children/young people who are suicidal, they need to ensure that the safety plan is completed collaboratively with healthcare professionals and children/young people and that it is appropriate for their age and development. There is also need for healthcare professionals to better recognize and respond to the needs of parents/carers who are caring for a child/young person with suicidal ideations/behaviours. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is some research indicating that safety planning is effective for use with children/young people, but such evidence has primarily been obtained from females and there is need for more evidence from male study populations. Further research on its use is needed for certain groups of children/young people including those who are care experienced, or identify as lesbian, gay, bisexual and transgender. This review highlighted that healthcare professionals need specific training before they deliver safety planning for children/young people. It was identified that parents/carers have additional needs and should be involved in safety planning. An additional resource specifically for parents/carers should be developed.

ABSTRACT

INTRODUCTION: Suicide is a leading cause of death for children and young people and its prevention is a global priority. Many Mental Health Services employ safety planning as a brief intervention. There is some evidence of safety planning effectiveness for adults, but little is known about its effectiveness with young people.

AIM

To synthesize research reporting safety planning effectiveness for children/young people with suicidal ideation and identify good practice recommendations.

INCLUSION CRITERIA

The review relates to safety planning around suicide prevention for children/young people aged less than 18 years, even if it was within a wider intervention. The review was inclusive of all clinical areas (including mental health, primary care, etc), any geographical location or social economic status and inclusivity around the method of delivery.

METHODS

A systematic scoping review of literature reporting effectiveness data for the use of safety planning with children/young people with suicidal ideation. The systematic scoping review protocol (pre-registered with Open Science Framework) followed Joanna Briggs Institute conduct guidance and PRISMA-ScR checklist.

DATA ANALYSIS AND PRESENTATION

Fifteen studies were reported during 2008-2021. Overall, there is promising, but limited, evidence of effectiveness for safety planning for children/young people but with complete evidence gaps for some demographic sub-groups. Evidence determined that healthcare professionals should deliver a safety planning intervention that is completed collaboratively, developmentally appropriate, and recognizes parental/carer involvement.

DISCUSSION AND IMPLICATIONS FOR PRACTICE

Further research is needed but current evidence suggests safety planning should be a routine part of care packages for children/young people with suicidal ideation proportionate to their needs. Developing/implementing these plans needs bespoke health professional training and additional support and resources for parents/carers should be developed.

Association of maternal mental health and drinking/smoking with adolescents' mental health based on the Korea National Health and Nutrition Examination Survey

Introduction

Depression is one of the major concerns in adolescence, with a global prevalence of approximately 5%. Diverse environmental factors can affect the development of depression depending on the individual developmental stage.

Methods

Using data from the Korea National Health and Nutrition Examination Survey (KNHANES), we aimed to investigate the association between socioeconomic factors and mental health in a population of non-clinically ill adolescents in Korea totaling 6,261 adolescents aged 12-18 years.

Results

Drinking, smoking, stress, depressed mood, suicidal ideation in adolescents, and stress, depressed mood, and suicidal ideation in mothers were identified as factors associated with adolescent depression. In addition to depressed mood and suicidal ideation, the higher perception of stress in mothers was related to higher stress perception, depressed mood, and suicidal ideation in adolescents. The association of adolescents' mental health with fathers' mental health was weaker than that with mothers' mental health. Additionally, increased smoking and drinking were commonly reported in adolescents with higher stress perception, depressed mood, and suicidal ideation.

Discussion

We conclude that close monitoring of mental health is required for adolescents with drinking and smoking habits and mothers with mental health problems.

The prevalence and risk of developing major depression among individuals with subthreshold depression in the general population

BACKGROUND

Subthreshold depression could be a significant precursor to and a risk factor for major depression. However, reliable estimates of the prevalence and its contribution to developing major depression under different terminologies depicting subthreshold depression have to be established.

METHODS

By searching PubMed and Web of Science using predefined inclusion criteria, we included 1 129 969 individuals from 113 studies conducted. The prevalence estimates were calculated using the random effect model. The incidence risk ratio (IRR) was estimated by measuring the ratio of individuals with subthreshold depression who developed major depression compared to that of non-depressed individuals from 19 studies (88, 882 individuals).

RESULTS

No significant difference in the prevalence among the different terminologies depicting subthreshold depression (Q = 1.96, p = 0.5801) was found. By pooling the prevalence estimates of subthreshold depression in 113 studies, we obtained a summary prevalence of 11.02% [95% confidence interval (CI) 9.78-12.33%]. The youth group had the highest prevalence (14.17%, 95% CI 8.82-20.55%), followed by the elderly group (12.95%, 95% CI 11.41-14.58%) and the adult group (8.92%, 95% CI 7.51-10.45%). Further analysis of 19 studies' incidence rates showed individuals with subthreshold depression had an increased risk of developing major depression (IRR = 2.95, 95% CI 2.33-3.73), and the term minor depression showed the highest IRR compared with other terms (IRR = 3.97, 95% CI 3.17-4.96).

CONCLUSIONS

Depression could be a spectrum disorder, with subthreshold depression being a significant precursor to and a risk factor for major depression. Proactive management of subthreshold depression could be effective for managing the increasing prevalence of major depression.

Brief and Ultra-Brief Suicide-Specific Interventions

The rising rates of suicide warrant effective treatments that can quickly help stabilize suicidal individuals and prevent future suicidal crises from occurring. Across the past few decades, there has been a rise in the development of ultra-brief (1-4 sessions) and brief suicide-specific interventions (6-12 sessions) to meet this need. This article reviews several prominent ultra-brief and brief interventions, including the Teachable Moment Brief Intervention, Attempted Suicide Short Intervention Program, Safety Planning Intervention, Crisis Response Planning, Cognitive Therapy for Suicide Prevention, Brief Cognitive-Behavioral Therapy for Suicide Prevention, Collaborative Assessment and Management of Suicidality, and the Coping Long-Term With Active Suicide Program. A brief review of each interventions' evidence base is also provided. Current challenges and directions for future research in testing the efficacy and effectiveness of suicide prevention initiatives are discussed.

Suicide-Related Outcomes Following Gender-Affirming Treatment: A Review

Gender-affirming treatment remains a topic of controversy; of particular concern is whether gender-affirming treatment reduces suicidality. A narrative review was undertaken evaluating suicide-related outcomes following gender-affirming surgery, hormones, and/or puberty blockers. Of the 23 studies that met the inclusion criteria, the majority indicated a reduction in suicidality following gender-affirming treatment; however, the literature to date suffers from a lack of methodological rigor that increases the risk of type I error. There is a need for continued research in suicidality outcomes following gender-affirming treatment that adequately controls for the presence of psychiatric comorbidity and treatment, substance use, and other suicide risk-enhancing and reducing factors. There is also a need for future systematic reviews given the inherent limitations of a narrative review. There may be implications on the informed consent process of gender-affirming treatment given the current lack of methodological robustness of the literature reviewed.

The effects of psychological treatments of depression in children and adolescents on response, reliable change, and deterioration: a systematic review and meta-analysis

Meta-analyses show that psychotherapies are effective in the treatment of depression in children and adolescents. However, these effects are usually reported in terms of effect sizes. For patients and clinicians, it is important to know whether patients achieve a clinically significant improvement or deterioration. We conducted such a meta-analysis to examine response, clinically significant change, clinically significant deterioration and recovery as outcomes. We searched four bibliographic databases and included 40 randomised trials comparing psychotherapy for youth depression against control conditions. We used a validated method to estimate outcome rates, based on means, standard deviation and N at baseline and post-test. We also calculated numbers-need-to- treat (NNT). The overall response rate in psychotherapies at 2 (±1) months after baseline was 39% (95% CI: 34-45) and 24% (95% CI: 0.19-28) in control conditions (NNT: 6.2). The difference between therapy and control was still significant at 6-12 months after baseline (NNT=7.8). Clinically significant improvement was found in 54% of youth in therapy, compared with 32% in control groups (NNT=5.3); clinically significant deterioration was 6% in therapy, 13% in controls (NNT=5.1); recovery was 58% in therapy, 36% in controls (NNT=3.3). Smaller effects were found in studies with low risk of bias. Psychotherapies for depression in youth are effective compared to control conditions, but more than 60% of youth receiving therapy do not respond. More effective treatments and treatment strategies are clearly needed. Trial registration https://osf.io/84xka.

Future Directions in Understanding and Interpreting Discrepant Reports of Suicidal Thoughts and Behaviors Among Youth

Both the quality and utility of youth suicide research depend on how we assess our outcomes of interest: suicidal thoughts and behaviors (STBs). We now have access to more STB assessments than ever before, with measures for youth that vary in what exact experiences are asked about, how such measures elicit information, when and how frequently measures are administered, and who the informants are. This growing armamentarium of assessments has the potential to improve the study and treatment of STBs among youth, but it hinges on meaningful interpretation of assessment responses. Interpretation can be especially challenging when different STB assessments yield conflicting information. Determining how to manage discrepant reports of STBs is a pivotal step toward achieving meaningfully comprehensive STB assessment batteries. Here, we outline several discrepant reporting patterns that have been detected, discuss the potential significance of these observed discrepancies, and present initial steps to formally investigate discrepant reports of STBs among youth. Developing coherent, interpretable, and comprehensive batteries assessing STBs among youth would address a fundamental step to uncovering etiology, improving clinical decision-making and case management, informing intervention development, and tracking prognosis.

The Influence of Social Media on Adolescent Suicide: Is It All Bad?

Current daily practices in many emergency departments throughout the United States include providing emergency stabilization and psychiatric care for adolescents presenting with suicidal ideations and attempts. Upon presentation for care, standard nursing practices are to initiate suicide precautions. These precautions include removing all personal items from the patient, including cell phones or other electronic devices and with it, their access to social media. Although many believe this removal gives adolescents a necessary break from their peers and the social pressures associated with adolescence in the 21st century, is this practice supported by current evidence? And does it benefit adolescents, or provide additional psychological stress and anxiety, thus exacerbating their current state of crisis? The current literature review examines these questions and reveals contradictory evidence supporting detrimental and constructive effects of social media removal during adolescent emergency treatment for suicidal behaviors. [Journal of Psychosocial Nursing and Mental Health Services, 61(4), 12-17.].

Suicide ideation and/or attempt with substance use and associated factors among the youth in northwest Ethiopia, community-based

BACKGROUND

Substance use is referring to the use of psychoactive substances like chat, cigarettes, alcohol, and others. The use of substances particularly (alcohol, chat, and cigarette) is a major mental health burden in developing countries including Ethiopia among youth. Suicide ideation and an attempt are thinking or trying to kill oneself that facilitates the act of a person intentionally causing his or her death. Suicide is one of the most serious mental health problems and has a great social impact in the world as it is currently the third leading cause of death for youth. Youth is defined as the period of life between childhood and maturity with an age interval of (15-25).

METHOD

A cross-sectional study design was used to assess the prevalence of suicidal ideation and attempts with substance use among youth in northwest Ethiopia. Multi-stage sampling techniques of stratified with simple random sample ware used. In the first stage, substance users are selected then as the second stage among substance users the burden of suicide behavior is assessed. ASIST, DASS-21, and other tools were used to assess suicidal behavior with substance use and associated factors. Data were edited, purified, and entered into Epi-data version 4.6 before being exported to the statistical package for social sciences version 20 for analysis of bi-variables to see the associations' p-value < 0.2 and multi-variables to identify the associated variables with a p-value of < 0.05 AOR and CI also done.

RESULTS

From a total of 372 substance user participants over all prevalence of suicidal ideation and attempt among youth was 54(14.5%) with 95% CI of (11.0,18.0) and 37(9.9%) with 95% CI (7.0, 13.0) respectively. Being female [AOR =2.36;95% CI:(1.19, 4.68)], poor social support [AOR =3.03; 95% CI: (1.11, 8.25)], and anxiety [AOR = 3.82: 95% CI; (1.96, 7.46)].

CONCLUSION AND RECOMMENDATIONS

The prevalence of suicidal ideation and attempt among substance users was 14.5 and 9.9% respectively therefore, immediate interventional actions needed to be administered to decrease the burden of suicide by reducing substance use and other associated factors.

Characteristics of Korean Children and Adolescents Who Die by Suicide Based on Teachers' Reports

We analyzed the clinical characteristics and suicide-related factors of students who died by suicide in Korea in 2016–2020, based on teachers’ reports. Using data on total suicide deaths (N = 654, mean age = 16.0, 52.6% boys) collected by the Ministry of Education of Korea, we investigated the demographic and clinical characteristics and suicide-related factors of suicide deaths in students aged 9–18 years. Considering gender, more boys (52.6%, N = 344) died by suicide than girls (47.4%, N = 310). About 425 (65.0%) of the suicides were among high school students. The most common suicide method was jumping from a high place (70.6%, N = 454), followed by hanging (25.7%, N = 165). Additionally, 9.4% (N = 48) of the students who died by suicide had a history of attempted suicide, 13.4% (N = 73) had attempted self-harm, and 12.8% (N = 48) were acquainted with someone who had died by suicide. Teachers observed 20.6% (N = 120) of the suicide warning signs at school. Girls tended to have higher rates of attempted suicide, emotional problems, and psychiatric disorders than boys. This study was conducted with the largest sample of Korean suicide students observed at school. Effective suicide-related mental health training for teachers could contribute to suicide prevention in students.

Adolescent Suicide—Understanding Unique Risks and Opportunities for Trauma Centers to Recognize, Intervene, and Prevent a Leading Cause of Death

Purpose of Review

This provides up-to-date epidemiology of adolescent suicide and risk factors for suicide and highlights the overlap of risks for suicide and injury. It reviews signs and symptoms, and the up-to-date evidence on screening for depression, post-traumatic stress disorder (PTSD), suicide, substance abuse, and lethal means, and offers strategies of implementation in trauma centers.

Recent Findings

The incidence of adolescent suicide has continued to rise in the USA to 6.5 per 100,000, with notable racial disparities. The risk factors are complex, but many pre-existing risk factors and sequela after injury such as exposures to violence, suicidal behaviors, substance abuse, depression and post-traumatic stress disorder, and specific injuries including traumatic brain injury and spinal cord injury have further emerged as risks. Studies show rates of suicidality as high as 30% in the acute care setting. There are short screening instruments that can be used to universally screen for depression and suicidality in adolescent trauma patients. Step-up models of care for PTSD are promising to increase screening and services after injury. Lethal means counseling, secure firearm storage practices, and firearm safety policies can reduce the risk of suicide.

Summary

Suicide is the second leading cause of death in US adolescents, and trauma patients have significant risk factors for mental illness and suicidality before and after injury. Trauma centers should strongly consider screening adolescents, establish strategies for mental health support and referrals, and provide lethal means counseling to help prevent suicide.

Development and Testing of an Emergency Department Quality Measure for Pediatric Suicidal Ideation and Self-Harm

OBJECTIVE

To develop and test a new quality measure assessing timeliness of follow-up mental health care for youth presenting to the emergency department (ED) with suicidal ideation or self-harm.

METHODS

Based on a conceptual framework, evidence review, and a modified Delphi process, we developed a quality measure assessing whether youth 5 to 17 years old evaluated for suicidal ideation or self-harm in the ED and discharged to home had a follow-up mental health care visit within 7 days. The measure was tested in 4 geographically dispersed states (California, Pennsylvania, South Carolina, Tennessee) using Medicaid administrative data. We examined measure feasibility of implementation, variation, reliability, and validity. To test validity, adjusted regression models examined associations between quality measure scores and subsequent all-cause and same-cause hospital readmissions/ED return visits.

RESULTS

Overall, there were 16,486 eligible ED visits between September 1, 2014 and July 31, 2016; 53.5% of eligible ED visits had an associated mental health care follow-up visit within 7 days. Measure scores varied by state, ranging from 26.3% to 66.5%, and by youth characteristics: visits by youth who were non-White, male, and living in an urban area were significantly less likely to be associated with a follow-up visit within 7 days. Better quality measure performance was not associated with decreased reutilization.

CONCLUSIONS

This new ED quality measure may be useful for monitoring and improving the quality of care for this vulnerable population; however, future work is needed to establish the measure's predictive validity using more prevalent outcomes such as recurrence of suicidal ideation or deliberate self-harm.

Predictors of Suicidal Thoughts in Children with Autism Spectrum Disorder and Anxiety or Obsessive-Compulsive Disorder: The Unique Contribution of Externalizing Behaviors

Children with autism spectrum disorder (ASD) are at elevated risk of suicidal ideation, particularly those with comorbid anxiety disorders and/or obsessive-compulsive disorder (OCD). We investigated the risk factors associated with suicidal ideation in 166 children with ASD and comorbid anxiety disorders/OCD, and the unique contribution of externalizing behaviors. Suicidal ideation was reported in the child sample by 13% of parents. Controlling for child age, sex, and IQ, perceived loneliness positively predicted the likelihood of suicidal ideation. In addition, externalizing behaviors positively predicted suicidal ideation, controlling for all other factors. Reliance on parental report to detect suicidal ideation in youth with ASD is a limitation of this study. Nonetheless, these findings highlight the importance of assessing and addressing suicidal ideation in children with ASD and comorbid anxiety disorders/OCD, and more importantly in those with elevated externalizing behaviors and perceptions of loneliness.

Safety Planning: Why It Is Essential on the Day of Discharge From In-patient Psychiatric Hospitalization in Reducing Future Risks of Suicide

Individuals who suffer from mental illness are at an increased risk for suicide. That risk is substantially higher in the post-discharge period from psychiatric hospitalization. Safety planning intervention (SPI) is a common intervention tool that is utilized to mitigate the risk of suicide. Current research notes promising results of SPI use in the emergency department (ED); however, there is limited research regarding SPI use during psychiatric hospitalization on the day of discharge. This paper aims to evaluate current research on the topic and establish a need for more widespread use of SPI during psychiatric hospitalization.

Association Between Suicide and Drinking Habits in Adolescents

Objectives

Adolescent suicide is a serious social problem. Adolescent alcohol use is one of the most important risk factors for adolescent suicide. This study aimed to identify the relationship between drinking habits and suicide among Korean adolescents.

Methods

Data from the 14th and 15th Korean Youth Risk Behavior Web-based Survey, conducted in 2018 and 2019, were used for analysis. Multiple logistic regression analysis was used to identify the relationship between drinking habits—including the age of drinking initiation, frequency of drinking, average drinking amount, frequency of drunkenness—and suicidal ideation, plans, and attempts.

Results

Even after adjusting for age, sex, school grade, academic achievement, socioeconomic status, depression, stress, and drinking habits, the frequencies of drinking and drunkenness increased the risk of suicide attempts. Suicide attempts were associated with the frequency of drinking in girls and middle school students, and with the frequency of drunkenness in boys and high school students.

Conclusion

This study identified associations between drinking habits (the age of drinking initiation, frequency of drinking, average amount of drinking, frequency of drunkenness) and suicidal behavior in adolescents. Our findings suggest that to prevent adolescent suicide, it might be necessary to investigate drinking habits, including the frequencies of drinking and drunkenness. Moreover, considering the differences in sex and school grade, it is important to include the individual group characteristics when evaluating drinking habits.

A qualitative content analysis study using electronic medical records to understand youth suicide attempts

PROBLEM

Suicide is the second leading cause of death for people aged 10-24 in the United States. The purpose of this study was to examine circumstances youth self-reported when presenting to hospitals due to a suicide attempt.

METHODS

A qualitative content analysis of clinicians' notes identified major themes of patients' lived experiences and circumstances leading up to suicide attempt.

FINDINGS

A total of 231 unique patient encounters were included in this study. Mean age of participants was 14.71 (SD = 2.04) the majority being female (75%) and Non-Hispanic White (48%). Four themes characterized contributing factors: (1) trauma, (2) relationship quality, (3) risky behaviors, and (4) personal emotions and symptoms.

CONCLUSIONS

Findings suggest commonalities among these youths' circumstances and experiences which may have precipitated a suicide attempt. These data will aid nurses and other health-care providers in understanding the complex, and often traumatic, histories of youth who attempt suicide. Improved knowledge in this area has the potential to direct improved screening, treatment, and referral protocols as well as suggest areas to focus prevention efforts.

A Meta-analytic Review: Psychological Treatment of Subthreshold Depression in Children and Adolescents

OBJECTIVE

Subthreshold depression has been found to be associated with considerable impairment and an increased risk of developing major depression. Although several randomized trials have examined the effects of psychological interventions for subthreshold depression in children and adolescents, no meta-analysis has integrated the results of these trials.

METHOD

We searched 4 bibliographic databases and included randomized trials comparing psychological interventions with control conditions in children and adolescents scoring above a cut-off of a depression questionnaire but not meeting diagnostic criteria for major depression (or persistent depressive disorder) according to a diagnostic interview. Effect sizes and incidence rates of major depression were pooled with random effects meta-analyses.

RESULTS

A total of 12 trials with 1,576 children and adolescents met inclusion criteria. The overall effect size indicating the difference between treatment and control at post-test was g = 0.38 (95% CI = 0.14-0.63), which corresponds to a number-needed-to-treat (NNT) of 8.4. Heterogeneity was moderate to high (I² = 61; 95% CI = 28-79), and there was significant risk of publication bias (p < .04). The 2 studies in children less than 12 years of age showed nonsignificant effects (g = 0.01; 95% CI = -1.16 to 1.18). We found no significant effect on the incidence of major depression at follow-up (relative risk = 0.52; 95% CI = 0.25-1.08), although this may be related to low statistical power.

CONCLUSION

Interventions for subthreshold depression may have positive acute effects in adolescents. There is currently insufficient evidence, however, that these interventions are effective in children less than 12 years of age, or that they prevent the onset of major depression at follow-up.

Suicidality Among Psychiatrically Hospitalized Lesbian, Gay, Bisexual, Transgender, Queer, and/or Questioning Youth: Risk and Protective Factors

Purpose: The study purpose was to compare suicide risk between lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ) and non-LGBTQ adolescents in a psychiatric hospital. Methods: Data were obtained from self-report measures completed by patients 12-17 years of age (n = 334) in a Midwestern psychiatric hospital from 2016 to 2017. Factors analyzed included sexual orientation, gender identity, suicidality, depression, nonsuicidal self-injury, abuse, substance use, bullying, perceived discrimination, and adult support. Results: Nearly one-third of patients identified as LGBTQ. A lifetime suicide attempt was reported by 69.6% of LGBTQ patients compared with 43.6% of non-LGBTQ patients. However, the prevalence of suicide attempts among LGBTQ patients with high adult support did not differ from that of non-LGBTQ patients. In the full logistic regression model adjusting for 13 factors, the adjusted odds ratio of a suicide attempt was 5.25 among transgender/questioning patients and 2.41 among nontransgender lesbian, gay, bisexual, queer, or questioning patients. All risk factors, apart from substance use, were more prevalent among LGBTQ than non-LGBTQ patients (p < 0.005). Among LGBTQ patients of color (Black/Latinx/Other), 91.3% had a lifetime suicide attempt versus 62.3% of White LGBTQ patients (p = 0.009). Conclusion: LGBTQ patients overall, and LGBTQ patients of color in particular, had higher rates of suicide attempts than non-LGBTQ patients. LGBTQ patients also had a higher prevalence of risk factors for suicide; however, the study variables did not fully explain the higher prevalence of suicide attempts. Future research should further examine possible risk factors for suicide among LGBTQ youth, such as stigma and discrimination.

Prospective Associations of Frequent Pain Symptoms With Suicidal Behavior in Adolescents

Chronic pain and suicidal behavior are prevalent in adolescents. This longitudinal study examined the associations between pain symptoms and suicidal behavior in adolescents. A total of 7,072 adolescents participated in a follow-up study of behavior and health in Shandong, China. A self-administered structured questionnaire was used to assess pain symptoms (headache, stomachache, and other nonspecific pain), insomnia, anxiety/depression, substance use, stressful life events, prior suicidal behavior, and family environment in November-December in 2015. One year later, a follow-up survey was conducted. Mean age of the sample was 14.6 years, and half were female. Of the sample, 44.8% and 8.4% reported having one or more pain symptoms "sometimes" and "often", respectively. A total of 22.4% and 10.6% reported having lifetime suicidal behavior at baseline and subsequent suicidal behavior over the 1-year follow-up, respectively. Frequent pain was significantly associated with increased risk of suicidal behavior at baseline (OR=1.64, 95%CI=1.32-2.03) and during the subsequent year (OR=1.50, 95%CI=1.17-1.93) while adjusting for adolescent individual and family covariates. Among adolescents without a history of prior suicidal behavior, frequent pain was significantly associated with an approximately 70% increased risk of incident suicidal behavior (OR= 1.69, 95%CI=1.14-2.51). In conclusion, frequent pain appears to be predictive of adolescent suicidal behavior one year later. PERSPECTIVE: This article presents the prospective associations of frequent pain symptoms with suicidal behavior in adolescents. Frequent pain was associated with a 50-70% increased risk of suicidal behavior 1 year later. The finding underscores the importance of pain assessment and treatment in comprehensive suicide prevention efforts in adolescents.

The Relations Between Identity Disturbances, Borderline Features, Internalizing Disorders, and Suicidality in Inpatient Adolescents

Previous studies have demonstrated positive associations between identity disturbances and suicidality in adolescents; however, mechanisms underlying these relationships are not well understood. The authors propose that borderline features and various internalizing disorders may mediate these relations. The aim of this study was to test a multiple mediation model of the associations between these constructs using structural equation modeling. Ninety-six inpatient adolescents aged 12-17 years completed the Assessment of Identity Development in Adolescents, the Childhood Interview for DSM-IV Borderline Personality Disorder, the Youth Self-Report, and the Columbia-Suicide Severity Rating Scale. Findings partly confirmed the theoretical model. Borderline features mediated the positive effect of identity disturbances on suicidal ideation severity. Mediations of withdrawn/depression and anxiety/depression on the effect of identity disruption on suicidal ideation intensity were demonstrated. Identity disruptions and borderline and depressive symptoms could be possible targets for interventions for youth experiencing suicidal ideation.

Trends of juvenile and adolescent suicides in North Tunisia: a 12-year study

OBJECTIVES

The aim of our study was to analyze the epidemiological characteristics for suicide methods and factors over a 12-year period among child suicides in Northern Tunisia and to compare juvenile and adolescent suicides.

STUDY DESIGN

This is a cross-sectional study.

METHODS

We included all child and adolescent suicide cases that took place in the North of Tunisia over a 12 year period (2005-2016). Data were collected from medical records and judicial inquiries and were classified into three sections: sociodemographic data, the circumstances of suicide, and the autopsy findings. Data were then compared between the 'juvenile suicide group' and 'the adolescent suicide group', according to the WHO definition.

RESULTS

Casualties were equally males and females, mostly adolescents (74.5%), aged 15 years old on average. Hanging was the most frequent suicidal method. A peak of frequency was observed in 2014.

CONCLUSION

Our results suggested to focus, among other preventive measures, on the role of media coverage of child suicides.

Childhood adversity, suicidality, and non-suicidal self-injury among children and adolescents admitted to emergency departments

PURPOSE

This population-based study explored the associations between childhood adversity and admission to emergency departments (EDs) with non-suicidal self-injury (NSSI) and with a suicide attempt.

METHODS

A nationally representative cross-sectional sample of 5-17-year-olds admitted to EDs (N = 143,113,677) from 2006 to 2015 was utilized to assess the associations between childhood adversities, NSSIs, and suicide attempts.

RESULTS

ED admissions with NSSI and admissions with a suicide attempt were associated with greater odds of exposure to individual childhood adversities (aORs: 1.34 to 5.86; aORs: 2.37 to 15.69, respectively). ED admissions with a suicide attempt were associated with greater odds of exposure to childhood adversities that might be perceived as less extreme or harmful (separation or divorce aOR: 15.69) than other adversities (death of a family member aOR: 13.38; history of physical abuse aOR: 9.56) as well as greater odds of exposure to three or more childhood adversities (aOR: 20.98).

CONCLUSION

Early detection of childhood adversities is important for identifying potential risk factors for self-harm. ED admission data can provide population-level surveillance to aid in these efforts and lead to more targeted and effective interventions aimed at reducing the negative effects of toxic stress that can result from exposure to childhood adversities.

Machine learning for suicide risk prediction in children and adolescents with electronic health records

Accurate prediction of suicide risk among children and adolescents within an actionable time frame is an important but challenging task. Very few studies have comprehensively considered the clinical risk factors available to produce quantifiable risk scores for estimation of short- and long-term suicide risk for pediatric population. In this paper, we built machine learning models for predicting suicidal behavior among children and adolescents based on their longitudinal clinical records, and determining short- and long-term risk factors. This retrospective study used deidentified structured electronic health records (EHR) from the Connecticut Children's Medical Center covering the period from 1 October 2011 to 30 September 2016. Clinical records of 41,721 young patients (10-18 years old) were included for analysis. Candidate predictors included demographics, diagnosis, laboratory tests, and medications. Different prediction windows ranging from 0 to 365 days were adopted. For each prediction window, candidate predictors were first screened by univariate statistical tests, and then a predictive model was built via a sequential forward feature selection procedure. We grouped the selected predictors and estimated their contributions to risk prediction at different prediction window lengths. The developed predictive models predicted suicidal behavior across all prediction windows with AUCs varying from 0.81 to 0.86. For all prediction windows, the models detected 53-62% of suicide-positive subjects with 90% specificity. The models performed better with shorter prediction windows and predictor importance varied across prediction windows, illustrating short- and long-term risks. Our findings demonstrated that routinely collected EHRs can be used to create accurate predictive models for suicide risk among children and adolescents.

The relations between childhood maltreatment, shame, guilt, depression and suicidal ideation in inpatient adolescents

BACKGROUND

Previous studies demonstrated positive relations between various forms of maltreatment and suicidal ideation in youth; however, mechanisms underlying these relationships are not well understood. We propose that the experience of maltreatment in childhood may lead to high levels of generalized guilt and shame, resulting in an increase of depressive symptoms and suicidal thoughts in adolescents. The aim of the current study was to test our model of relations between these constructs using path analysis.

METHODS

112 inpatient adolescents aged 12-17 years completed the Childhood Trauma Questionnaire to measure various types of maltreatment, the Personal Feelings Questionnaire to evaluate generalized guilt and shame, the Beck Depression Inventory-II to assess depressive symptoms, and the Columbia-Suicide Severity Rating Scale to assess suicidal ideation.

RESULTS

Findings partly confirmed the theoretical model. Indirect positive effects of sexual and emotional abuse, as well as emotional and physical neglect on suicidal ideation via generalized self-conscious emotion and/or depression were demonstrated. In contrast to our predictions, indirect negative effects of physical abuse on suicidal thoughts via generalized guilt and shame and depression were found.

LIMITATIONS

Sample characterized by predominately Caucasian inpatient adolescents from financially stable and well-educated environments, over-reliance on self-report measures and the lack of a longitudinal design were main limitations of the study.

CONCLUSIONS

The study provides novel information on the potential mechanisms underlying the association between childhood maltreatment and suicidal ideation in adolescents. Generalized guilt and/or shame could be possible targets for interventions for victims of some forms of maltreatment to reduce depressive symptoms and suicidal ideation.

Future Directions for Optimizing Clinical Science & Safety: Ecological Momentary Assessments in Suicide/Self-Harm Research

OBJECTIVE

Mobile technology has facilitated rapid growth in the use of intensive longitudinal methods (ILM), such as ecological momentary assessments (EMA), that help identify proximal indicators of risk in real-time and real-world settings. To realize the potential of ILM for advancing knowledge regarding suicidal and self-injurious thoughts and behaviors (SITB), this article aims to provide a systematic review of safety protocols in published ILM studies of youth SITB, highlight considerations for maximizing safety, and offer an agenda for future research.

METHOD

We conducted a systematic review of risk management strategies in published studies applying ILM to assess SITB in youth.

RESULTS

The review indicated diverse safety strategies, with near-universal use of preventive strategies before beginning ILM surveys. Strategies for participant protection during the survey period included automated protective messages to seek support when elevated risk was detected; and staff-led strategies, some of which included active outreach to parents/caregivers when youth responses suggested elevated risk. Studies assessing suicidality all provided staff-led follow-up. There was minimal information on youth reactivity to intensive longitudinal assessments of SITB. Available evidence did not suggest increased suicidal ideation, suicide attempts, self-injurious behavior, or deaths with ILM.

CONCLUSIONS

Based on the review, we propose a research agenda to inform safety procedures in ILM research and a model for managing risk in future ILM studies of youth SITB. This model begins with a needs assessment and proposes a "goodness of fit" approach for matching safety procedures to the specific needs of each ILM study.

Factors associated with psychiatric readmission of children and adolescents in the U.S.: A systematic review of the literature

OBJECTIVE

A systematic review of research assessing factors associated with inpatient psychiatric readmission of children and adolescents.

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we searched 8 databases (1994-2018) to identify relevant articles on factors associated with youth psychiatric readmission. Selected articles addressed one or more factors associated with psychiatric readmission for children and adolescents (≤21 years of age) admitted to a psychiatric hospital in the United States for a primary mental health diagnosis. Two authors independently reviewed article abstracts, titles, and text.

RESULTS

Of 7903 retrieved articles, 30 studies met inclusion criteria. Analyzed variables were categorized according to child demographic and clinical characteristics; family, provider, and community characteristics; and treatment and aftercare characteristics. Available studies were markedly heterogeneous in methodology and outcomes. Factors associated with an increased risk of readmission included greater symptom severity, clinical diagnoses such as psychosis and affective disorders, suicidal behavior and self-injury, poor family functioning, and longer lengths of index hospital stay.

CONCLUSIONS

Controlled trials of interventions to improve care and reduce recidivism for psychiatrically hospitalized youth are needed. Future research will benefit from a guiding theoretical framework, more representative samples, and standardized exposure/outcome measures.

The association between leptin receptor polymorphism and suicidal behaviour in depressed adolescents

Objective: Suicide is the second leading cause of death in adolescence. Genetic studies implicate the genetic component of suicide independent from associated psychiatric disorder. Although genetics is an important factor that might be associated with suicide, limited progress is achieved to identify the candidate genes in adolescents.Methods: The study included 97 patients and 106 controls. Five leptin receptor single nucleotide polymorphism (SNP) region examined. Depressive scores were measured with Children Depression Inventory and suicidal behaviour was measured by Suicide Probability Scale. Logistic and linear regression analysis used for determining to predictors.Results: In linear regression analysis (R²: 0.786) both previous suicide attempt (B:5.553, t:2.613 p: .035) and having a mutant allele in rs1171276 SNP region (B:4.346 t:2.220 p: .048) have been associated with suicidal behaviour. In logistic regression analysis, family history of depression (p < .0001, OR: 4.2 [1.7-9.6]) and number of stressful life events (p: .001, OR: 1.7 [1.3-2.1]) predicted depression significantly.Conclusion: Leptin receptor polymorphism could result in an increase in impulsive behaviour and suicide scores with leptin resistance. Our research is the first study to investigate the relationship between depression, suicidal behaviour and leptin receptor polymorphism in adolescent sample. Similar studies could be carried out on a community basis.KEY POINTSAn association has been found between rs1171276 single nucleotide polymorphism of leptin receptor and the suicide probability scores in depressed adolescents.Family history of depression and number of stressful life events predict depressive scores significantly.Leptin receptor single nucleotide polymorphism may be a risk factor for adolescent suicide by increasing impulsive behaviour.

Predictors of Traumatic Suicide Attempts in Youth Presenting to Hospitals with Level I Trauma Centers

BACKGROUND

Limited research exists examining the predictors of suicide attempts by mechanism.

OBJECTIVE

The purpose of this study was to examine predictors of traumatic suicide attempts in youth.

METHODS

Data came from patients 5-18 years of age presenting because of a suicide attempt at 2 hospitals in Central Texas with level I trauma centers. Univariate logistic regression examined the association between traumatic suicide attempts and variables describing the patient's demographic, mental health, and social information. We used the Mann-Whitney U test to examine the association between traumatic suicide attempts and the continuous variable of age.

RESULTS

Of 231 patients included in this study, most were female (75.8%), non-Hispanic white (48.1%), and had a median age of 15.0 years (interquartile range 14-16). Compared with patients presenting because of an intentional overdose, patients presenting because of traumatic suicide attempts were associated with a reported criminal history (odds ratio [OR] 14.50 [95% confidence interval {CI} 3.84-54.82]), reported Child Protective Services history (OR 3.26 [95% CI 0.99-10.77]), being publicly insured or uninsured (OR 1.80 [95% CI 1.02-3.19]), male (OR 2.37 [95% CI 1.28-4.38]), and identifying as Hispanic (OR 2.01 [95% CI 1.10-3.68).

CONCLUSIONS

Our findings inform targeted preventative resources and education efforts to populations of greatest need.

Constant observation of pediatric patients at risk for self-harm and suicide: An evidence-based practice inquiry

Suicide is a leading cause of death for pediatric patients in the United States. The utilization of protective observation strategies, namely constant observation, is a regulatory recommendation as part of a comprehensive suicide prevention plan for hospitalized behavioral health patients. Constant observation is the increased level of observation and supervision with continuous one-to-one monitoring techniques, taken to assure the safety and well-being of a patient and others in the patient care environment (Moore et al., 1995). This evidence-based practice inquiry describes a search for the best evidence on constant observation practices ensuring the safe care of pediatric patients at risk for self-harm or suicide. The findings included no high-level evidence, however four literary themes related to the challenges of constant observation emerged: confusing language and definitions, untested models of care, important privacy issues and lack of pediatric observation strategies for patients at risk for self-harm and suicide. Impaired communication underscored each of the themes.

Gender-based Multilevel Analysis of Influential Factors for Suicide Attempts among At-risk Non-referred Adolescents in Korea

Objective

Effective suicide prevention for at-risk adolescents requires increased access to medical treatment. Investigating the unique characteristics of suicide in this vulnerable at-risk non-referred sample can contribute to establishing effective suicide prevention policies. This study aimed to (a) examine at-risk non-referred adolescents’ suicide attempt rate, (b) investigate influential multilevel factors in predicting these adolescents’ suicide attempts, and (c) compare the results of (a) and (b) by gender.

Methods

A total of 401 samples (216 boys and 185 girls) were recruited through a school-based mental health project for at-risk adolescents. Multivariate hierarchical logistic regression analyses were performed at the individual-, contextual-, and protective levels to evaluate three multilevel models as well as to investigate predictabilities for the overall group and by gender.

Results

The suicide attempt rate of the overall sample was 29.4% (boys: 18.1%, girls: 42.7%), which was significantly higher than that of community samples. For boys, individual-level predictors (depression and conduct problems) had the most significant contribution in predicting suicide attempts. In contrast, for girls, protective-level predictors (family satisfaction) contributed the most to the prediction of suicide attempts, followed by contextual-level predictors (academic grades).

Conclusion

This study is an important step in understanding the unique characteristics of at-risk non-referred adolescents who have not yet been considered in mental health policies. Improving medical accessibility will be the first step in establishing effective suicide prevention policies for these vulnerable samples.

Meta-Analysis: 13-Year Follow-up of Psychotherapy Effects on Youth Depression

OBJECTIVE

Youth depression is a debilitating condition that constitutes a major public health concern. A 2006 meta-analysis found modest benefits for psychotherapy versus control. Has 13 more years of research improved that picture? We sought to find out.

METHOD

We searched PubMed, PsychINFO, and Dissertation Abstracts International for 1960 to 2017, identifying 655 randomized, English-language psychotherapy trials for individuals aged 4 to 18 years. Of these, 55 assessed psychotherapy versus control for youth depression with outcome measures administered to both treatment and control conditions at post (κ = 53) and/or follow-up (κ = 32). Twelve study and outcome characteristics were extracted, and effect sizes were calculated for all psychotherapy versus control comparisons. Using a three-level random-effects model, we obtained an overall estimate of the psychotherapy versus control difference while accounting for the dependency among effect sizes. We then fitted a three-level mixed-effects model to identify moderators that might explain variation in effect size within and between studies.

RESULTS

The overall effect size (g) was 0.36 at posttreatment and 0.21 at follow-up (averaging 42 weeks after posttreatment). Three moderator effects were identified: effects were significantly larger for interpersonal therapy than for cognitive behavioral therapy, for youth self-reported outcomes than parent-reports, and for comparisons with inactive control conditions (eg, waitlist) than active controls (eg, usual care). Effects showed specificity, with significantly smaller effects for anxiety and externalizing behavior outcomes than for depression measures.

CONCLUSION

Youth depression psychotherapy effects are modest, with no significant change over the past 13 years. The findings highlight the need for treatment development and research to improve both immediate and longer-term benefits.

Assessment and Management of Suicide Risk in Children and Adolescents

This article presents a pragmatic approach to assessing and managing suicide risk in children and adolescents. We first present general recommendations for conducting risk assessments with children and adolescents, followed by an algorithm for designating risk. Risk assessment and designation should be based on both distal (i.e., a prior history of self-harm behaviors) and proximal (i.e., suicide ideation, plans, intent, and preparations) predictors of suicide attempt. We then discuss safety planning as an easy-to-implement approach for intervening and managing suicide risk when working with children and adolescents. We end with a case example illustrating the implementation of risk assessment, risk designation, and safety planning with an adolescent client and her mother.

CHILD SUICIDE: FAMILY’S REACTIONS

Introduction: Suicide is a major public health problem, in which relatives play an important role in the prevention of the said problem. However, suicide and suicidal behavior affect the relatives’ lives profoundly, both emotionally and socially. Aim: This study is an initial investigation of families’ emotional and behavioral responses to adolescents’ suicide Methodology: An extensive literary review of relevant articles for the period 2000-2017, was performed using Medline, PubMed and Google databases, with the following key words: “child suicide, parent’s reactions, bereavement, risk factors, warnings sign, and mental health problems”. Results: Suicide is uncommon in childhood but becomes an extremely serious issue among adolescents. Several risk factors have been identified and include the presence of psychiatric illness, a previous suicide attempt, family factors, substance abuse, sexual and physical abuse, or bullying. The death of a child of any age is extremely painful for parents. Most parents experience a profound sense of guilt, shame, pain, depression when harm comes to their child, even if through no fault of their own. The same feelings are often present and are associated with help seeking in siblings bereaved by suicide. All of these factors lead to a devastating grief that is much longer lasting than most people realize. Conclusion: Families that have experienced a suicide present severe prolonged grief with many psychological and physical symptoms such as depression, feelings of guilt, shame, pain, heart failure, hypertension, diabetes. However, the psychosocial impact on families is a very important issue who needs further investigation.

Recent advances in understanding and managing self-harm in adolescents

Adolescent suicide is a serious public health problem, and non-suicidal self-injury (NSSI) is both highly comorbid with suicidality among adolescents and a significant predictor of suicide attempts (SAs) in adolescents. We will clarify extant definitions related to suicidality and NSSI and the important similarities and differences between these constructs. We will also review several significant risk factors for suicidality, evidence-based and evidence-informed safety management strategies, and evidence-based treatment for adolescent self-harming behaviors. Currently, dialectical behavior therapy (DBT) for adolescents is the first and only treatment meeting the threshold of a well-established treatment for self-harming adolescents at high risk for suicide. Areas in need of future study include processes underlying the association between NSSI and SAs, clarification of warning signs and risk factors that are both sensitive and specific enough to accurately predict who is at imminent risk for suicide, and further efforts to sustain the effects of DBT post-treatment. DBT is a time- and labor-intensive treatment that requires extensive training for therapists and a significant time commitment for families (generally 6 months). It will therefore be helpful to assess whether other less-intensive treatment options can be established as evidence-based treatment for suicidal adolescents.

Suicidal ideation and suicide attempts among Tunisian adolescents: prevalence and associated factors

Introduction

Studies directed on suicidal behavior in North African adolescents are rare. This study was conducted to estimate the prevalence of suicidal thoughts and attempts among high school students in Tunisia and to determine factors associated with this suicidal behavior.

Methods

This is an analytical cross-sectional study composed of a population containing 821 high school students obtained through cluster sampling. The participants completed a pre-established form related to socio-demographic characteristics and anxiety symptoms, the Suicide Behavior Questionnaire-Revised, the Beck depression scale, and the Rosenberg self-esteem scale.

Results

The mean age of the adolescents was 17.7±0.97 years. Prevalence of suicidal behavior was 26.9% for brief passing suicidal thoughts, 9.6% for serious suicidal thoughts, and 7.3% for suicide attempts. Six determining factors of suicidal behavior were found: female gender (OR=2.56 (1.32-4.95); p= 0.005), personal history of depression (OR=2.29 (1.38-3.80); p=0.001), tobacco smoking (OR=3.59 (1.61-8.01); p=0.002), current depression symptoms (OR=5.50 (2.14-14.11); p<0.001), history of non-suicidal self-injurious behavior (OR= 3.16 (2.05-4.86); p<0.001), and low self-esteem (OR=2.74 (1.71-4.38); p<0.001).

Conclusion

Suicidal ideation and attempts are frequent among Tunisian adolescents and represent a serious public health problem. An urgent national prevention program is required.

Children Are Different: Liability Issues in Working With Suicidal and Dangerous Youths

While many of the principles of assessing risk to self and others in adults are applicable to risk assessments of children and adolescents, developmental and legal factors regarding youths give rise to some significant differences. This article highlights major differences in assessing and managing risk in working with suicidal and homicidal youths and gives suggestions for reducing clinicians' liability in these challenging cases.

The role of dissociation and abuse among adolescents who self-harm

OBJECTIVES

Retrospective recall of dissociative symptoms has been found to mediate the association between childhood abuse and deliberate self-harm (DSH) in later life. To disentangle the effect of recall bias, we tested whether dissociation symptoms ascertained during an acute DSH presentation mediates this link.

METHOD

All participants with DSH were recruited during emergency presentation. Seventy-one individuals aged 11-17 years with overdose (OD) and/or self-injury (SI) participated in semi-structured interviews and psychiatric assessment to measure abuse and dissociation. An age- and gender-matched comparison group of 42 non-psychiatric patients admitted to the same service were also assessed.

RESULTS

The DSH groups reported significantly higher levels of abuse and dissociation compared to comparison group. Dissociation significantly mediated the association between abuse and DSH. Of the four dissociation subtypes, 'depersonalisation' was the primary mediator. Adolescents with chronic patterns of DSH and the 'OD + SI' self-harm type reported more severe dissociation.

CONCLUSION

Exposure to abuse significantly increased the risk of DSH in adolescence. This association was mediated by dissociation. Our findings suggest a possible dose-response relationship between dissociation with DSH chronicity and the 'OD + SI' self-harm type, implicating the importance of evaluating dissociation and depersonalisation symptoms as well as abuse exposure in DSH management.

Suicide Risk Assessment and Management Training Practices in Pediatric Residency Programs: A Nationwide Needs Assessment Survey

PURPOSE

Youth suicide is a public health emergency, and its prevention is a national imperative. Pediatric providers are critical to risk assessment, triage, and intervention, yet little is known about the content, quality, and perceived adequacy of suicide prevention pediatric residency training. We thus sought to (1) characterize suicide risk assessment and management training practices in pediatric residency programs nationwide and (2) assess areas of training need to guide curricular development.

METHODS

An online nationwide needs assessment was distributed to all 204 pediatric residency program directors (PDs) and 494 pediatric chief residents (CRs) through the Association of Pediatric Program Directors listservs (May to June 2017). Descriptive statistics and comparisons between PDs and CRs are reported.

RESULTS

Ninety-five PDs and 210 CRs (47% and 43% response rate, respectively) completed the survey. Although 82% of respondents rated suicide prevention training in residency as "very" or "extremely" important, a minority (18% PDs and 10% CRs) reported adequate preparation relative to need. Formal training was not universal (66% PDs and 45% CRs) and practices varied across programs (PD median = 3 hours [interquartile range: 1-4.5 hours], CR median = 1.5 hours [interquartile range: 0-3 hours]). Top-ranked educational priorities included interviewing adolescents about risk, risk factor identification, and locating community resources. Training barriers included limited time, lack of training resources, and need for additional expert faculty to guide training.

CONCLUSIONS

PDs and CRs reported constraints to suicide prevention training for pediatric residents despite high perceived importance and need. Programs may benefit from explicit guidelines and standardized curricula that emphasize educational priorities, building on these findings.

Risk factors for the transition from suicide ideation to suicide attempt: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Prior research has shown that most known risk factors for suicide attempts in the general population actually predict suicide ideation rather than attempts among ideators. Yet clinical interest in predicting suicide attempts often involves the evaluation of risk among patients with ideation. We examined a number of characteristics of suicidal thoughts hypothesized to predict incident attempts in a retrospective analysis of lifetime ideators (N = 3,916) drawn from a large (N = 29,982), representative sample of United States Army soldiers. The most powerful predictors of first nonfatal lifetime suicide attempt in a multivariate model controlling for previously known predictors (e.g., demographics, mental disorders) were: recent onset of ideation, presence and recent onset of a suicide plan, low controllability of suicidal thoughts, extreme risk-taking or "tempting fate," and failure to answer questions about the characteristics of one's suicidal thoughts. A predictive model using these risk factors had strong accuracy (area under the curve [AUC] = .93), with 66.2% of all incident suicide attempts occurring among the 5% of soldiers with highest composite predicted risk. This high concentration of risk in this retrospective study suggests that a useful clinical decision support model could be constructed from prospective data to identify those with highest risk of subsequent suicide attempt. (PsycINFO Database Record

Youth Suicide Attempt Nomenclature Used in Two Central Texas Hospitals

Abstract. Background: Surveillance systems capturing instances of self-directed violence (SDV) continue to lack uniform nomenclature and classification methodology. Aims: To apply and compare two retrospective surveillance approaches to youth experiencing SDV presenting to two urban hospitals with Level I Trauma Centers. Method: Two suicide attempt surveillance methods where retrospectively applied to our SDV cohort: (a) a rigorous method facilitated by medical record review and application of standardized classification; and (b) a common surveillance method conducted by systematic queries of suicide attempt key terms and diagnosis codes among hospital databases. Results: Rigorous surveillance identified 249 patients attempting suicide. The common method's querying suicide attempt in the chief complaint field had a high positive predictive value and specificity; however, sensitivity was low. Limitations: Authors were unable to determine whether all SDV encounters during the study timeframe were identified for initial screening owing to the hospital's lack of a uniform nomenclature or classification system. Conclusion: Results showed underreporting of suicide attempt cases, inadequate sensitivity and specificity in common surveillance methods, and skewed demographic representation compared with the rigorous surveillance method. This study elucidates the negative impact of inconsistent SDV nomenclature including impeding effective patient identification, treatment, surveillance, and generalizable research.